Three Part Question

Clinical Scenario

A 14 year old restrained male was involved in a MVA. He has a fractured forearm but no other significant injuries. He is currently alert and oriented times three and does not complain of abdominal pain. Is physical exam combined with laboratory studies sufficient to exclude any significant intraabdominal injury (IAI) in this child?

Retrospective review, low prevalence of disease (4.8%), potential bias of physical exam in phase II as these patients were previously known to have IAI, lack of generalizability to younger patients and those with neurologic impairment, lack of universal lab testing (only 59% of pts had AST/ALT done)

351 children (<16yrs) with possible blunt abdominal trauma, 23 variables potentially associated with IAI were determined and logistic regression and recursive partitioning were used to identify variables and develop predictive models

Retrospective chart review, single center, all class I and II pediatric blunt traumas

Abdominal tenderness

OR 40.7 (10.7-155), p <0.01

Retrospective study, no uniformity in laboratory and CT scan testing, management by trauma surgeon may have lead to bias, small sample size, difficult to interpret decision tree

Abdominal abrasion

OR 16.8 (3.4-83.8), p<0.0001

Abdominal ecchymosis

OR 15.8 (1.7-142.3), p<0.05

ALT

OR 1.0 (1.01-1.03), p<0.0001

Injury related to MVA

OR 0.2 (0.1-0.6), p<0.01

Hematocrit

OR 0.9 (0.8-0.9), p<0.05

Abnormal abdominal exam +AST>131

88% of children with sens 100% spes 87%

Holmes et al2002USA

1095 children <16 years old who sustained blunt trauma and were at risk for IAI had physical exam and laboratory data collected

Prospective observation study, children had complete physical exam, CBC, AST, ALT, and urinalysis and CT or laparotomy at physician's discretion

Not all children had abdominal CT possibly creating evaluation bias, single-centered, low prevalence of disease

Low systolic BP

Sens 10% spec 98% PPV 42% NPV 91%

Abd tenderness

Sens 58% spec 71% PPV 18% NPV 94%

Femur fracture

Sens 10% spec 98% PPV 19% NPV 91%

ALT >125 or AST>200

Sens 50% spec 96% PPV 54% NPV 95%

Urinalysis >5rbc/hpf

Sens 50% spec 89% PPV 32% NPV 94%

Comment(s)

All the studies were single-centered with relatively small prevalence and were unblinded, possibly creating bias. Most common findings suggesting IAI included abdominal pain or abnormal abdominal exam, microscopic haematuria and elevated hepatic transaminases. They were unable to generalise the results to preverbal children (<3 years old) and to children with decreased level of consciousness (GCS <13).

Clinical Bottom Line

In paediatric blunt trauma patients over 3 years old with a GCS of 15, physical examination combined with laboratory testing such as CBC, AST/ALT, and U/A are a good predictor of IAI and, if normal, abdominal CT in not warranted.